Platelet-rich plasma improves acute and chronic anal fissure, a randomized control trial.

Anal fissure is one of the most prevalent diagnosis in patients with anorectal symptoms. Depending on the chronicity, treatment choices vary, from topical and conservative management to operative ones. PRP is a blood-derived product with a three to five-fold platelet count and can be used for restorative purposes. The objective of this study is to assess the therapeutic effect of intralesional PRP in acute and chronic anal fissures and comparing it with the classic topical approach. We included 94 patients with acute and chronic anal fissures and divided them into intervention and control groups. Control patients were treated only with topical compounds, and the intervention group received one dose of intralesional autologous PRP plus the same classic treatment. We assessed patients 2 weeks, 1 month, and 6 months later. The mean pain score in the intervention group was significantly lower than control groups in all visits (p-value <0.001). During the follow-ups, the bleeding rate was significantly lower in the intervention group, so in the sixth month, the bleeding was 4% in the intervention group against 32% of the control (p-value <0.001). The healing rate assessed by examination was 96% in the intervention group against 66% in the control in the sixth month (p-value <0.001). Although there may be no significant difference in healing rate between groups in the acute anal fissure, the PRP group is significantly superior in the chronic setting. We concluded that in anal fissure treatment, PRP plus topical products are significantly superior to alone topical treatment.

The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure.

AIM: The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross et al., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology. METHODS: The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using 'grade'. RESULTS: This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG. CONCLUSION: This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure.

INTRODUCTION: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS: A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS: In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Mucosal vs. cutaneous advancement flaps for the treatment of chronic anal fissures: a randomized clinical trial.

PURPOSE: The aim of this study was to compare two surgical treatment methods for chronic anal fissures (CAF), mucosal advancement flap anoplasty (MAFA) and cutaneous advancement flap anoplasty (CAFA). METHODS: A randomized, blinded clinical trial was conducted on patients with CAF refractory to medical treatment referred to a tertiary-level hospital between January 2021 and December 2022. The patients were assigned to two groups by block randomization and were compared in terms of outcome, pain reduction, and complications. RESULTS: There were 30 patients (male to female ratio 2:3, median age 42 years [range 25-59 years]). Both techniques reduced anal pain significantly (p = 0.001); however, there were no significant differences between MAFA and CAFA groups in recurrence, duration of healing, postoperative pain, and postoperative bleeding. No patient suffered from fecal incontinence (Wexner score = 0) or flap necrosis postoperatively. Only two patients in the MAFA group (1 and 3 months after surgery) and one patient in the CAFA group (2 months after surgery) had recurrence (total recurrence rate = 10%, healing rate = 90%). All of the patients were satisfied with their surgical results. CONCLUSION: Mucosal and cutaneous anal advancement flap techniques are effective and comparable surgical procedures for the treatment of chronic anal fissures with minimal complications, fast healing process, and minimal postoperative pain and complications. CLINICAL TRIAL ID: IRCT20120129008861N4 ( www.irct.ir ).

A systematic review and meta-analysis of the efficacy of topical sphincterotomy treatments for anal fissure.

BACKGROUND: Anal fissure is a common condition that can be treated medically or surgically. Chemical sphincterotomy is often used before surgical intervention. This study aims to evaluate the effectiveness of topical agents for chemical sphincterotomy on healing of anal fissures and side-effects. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant systematic review was performed using MEDLINE, EMBASE, Scopus, and CENTRAL databases. Eligible studies included randomized controlled trials which compared topical sphincterotomy agents with topical placebo agents or each other. Studies that included surgical treatments were excluded. Overall evidence was synthesized according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: Thirty-seven studies met the study selection criteria. Seventeen studies show that glyceryl trinitrate (GTN) was significantly more likely to heal anal fissure than placebo (relative risk (RR) = 1.96, 95% confidence interval (95%CI) = 1.35-2.84, I2 = 80%). Eleven studies showed a marginally significant difference between healing rates for diltiazem vs GTN, RR = 1.16, (1.01-1.33) I2 = 48%. There was no significant difference in healing between diltiazem and placebo, RR = 1.65, (0.64-4.23), I2 = 92%. GTN significantly reduced pain on the visual analog scale compared to the placebo group, MD-0.97 (-1.64 to -0.29) I2 = 92%. There was high certainty of evidence that GTN was significantly more likely to cause headache than placebo (RR = 2.73 (1.82-4.10) I2 = 58%) and diltiazem RR = 6.88 (2.19-21.63) I2 = 17%. CONCLUSION: There is low certainty evidence topical nitrates are an effective treatment for anal fissure healing and pain reduction compared to placebo. Despite widespread use of topical diltiazem, more evidence is required to establish the effectiveness of calcium channel blockers compared to placebo.

Comprehensive literature review of the applications of surgical laser in benign anal conditions.

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO2 laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

Health and quality of life among a cohort of patients having lateral internal sphincterotomy for anal fissures.

AIM: The aim of this study is to report changes in health-related quality of life attributable to lateral internal sphincterotomy for treatment of anal fissure. There is very little evidence on whether the overall health-related quality of life of patients is detrimentally affected by the condition, or which aspects of self-perceived health status improve after lateral internal sphincterotomy. This study will articulate which aspects of health tend to improve and guide postoperative expectations appropriately. Knowledge gained from this study may also identify gaps in an individual patient's episode of care. METHOD: Patients were prospectively identified when they consented to surgical treatment of their anal fissure and were contacted by phone to participate. Participants completed a number of patient-reported outcomes preoperatively and 6 months postoperatively. Faecal incontinence-related quality of life, pain and depression were measured at both time points. The severity of faecal incontinence was measured at both times. RESULTS: Participants reported high levels of pain preoperatively. Postoperatively, improvement in pain exceeded the threshold of clinical relevance (P < 0.01). Thirty-five per cent of participants reported significant effects of faecal incontinence preoperatively, while 26% did so postoperatively. Participants with multiple comorbidities were more likely to report faecal incontinence postoperatively than preoperatively. CONCLUSION: This study reports that lateral internal sphincterotomy improved pain symptoms without adverse effects on continence. Not all domains of health-related quality of life were similarly positively affected by anal fissure repair.

Colorectal Surgery Review for Primary Care Providers.

Anorectal conditions are one of the most common problems evaluated by primary care physicians. Most patients present with rectal pain, rectal bleeding, or purulent drainage per rectum. Colorectal conditions have overlapping symptoms. Thorough history and careful anorectal examination can differentiate common anorectal conditions like hemorrhoids, anorectal abscesses, anal fistula, anal fissure, and anal condyloma. Most of these conditions can be diagnosed and treated without imaging.

[Experience of using an individual approach in the anal fissures treatment]. / Opyt ispol'zovaniia individual'nogo podkhoda v lechenii anal'nykh treshchin.

AIM: To objectify the criteria for choosing the method of treatment of anal fissures, to determine the indications for surgery and sphincterotomy. MATERIAL AND METHODS: The results of treatment of 206 patients with chronic and acute anal fissures between the ages of 17 to 75 years are analyzed. The posterior anal fissure was detected in 175 (84.9%) patients, the front - in 18 (8.7%), the combination of fissures was noted 13 (6.3%) times. The history of the disease - from 1 month to 12 years. The examination included analysis of clinical data, indicators of pre- and postoperative anorectal manometry, endorectal ultrasound. The period of postoperative monitoring is from 6 to 12 months, control examinations with a functional study of the anal sphincters were carried out 1 and 2 months after healing. Concomitant hemorrhoids were noted in 65 (31.5%) patients, of which 20 (9.7%) patients were simultaneously hemorrhoidectomized. In 11 (5.3%) patients, simultaneous operations were performed in the presence of paraproctitis, rectal fistula. RESULTS: In 77.8% of patients with acute fissures, the use of conservative therapy, which included myotropic antispasmodics and local application of glycerol trinitrate made it possible to achieve healing of fissures without surgery. Operated 185 (89.8%) patients. With an increase in the basal anal pressure at the level of the internal sphincter, an increase in the average pressure in the anal canal, a decrease in the amplitude and duration of the rectoanal reflex, the indications for dosed sphincterotomy were determined in 167 patients. At the same time, in 117 persons, the excision of fissures was supplemented with a lateral 'closed' sphincterotomy, in 50 cases the posterior 'open' dosed sphincterotomy was performed. In 18 (9.7% of the operated ones) patients in the absence of sphincter hypertonus, the fissures were excised without sphincterotomy. The best functional results were obtained after performing the lateral 'closed' subcutaneous sphincterotomy. It was noticed that in the absence of characteristic complaints and clinical manifestations of incontinence, in 14 patients there was a decrease in the average pressure in the anal canal at rest and with volitional contraction. At the same time, 6 patients out of 14 belonged to the older age groups, and in 9 women there was a rectocele, pelvic floor prolapse. Postoperative incontinence was not observed. Recovery with complete epithelialization of the anoderm defect and the absence of complaints was achieved in 191 (92.7%) patients, satisfactory results (healing of fissures in the presence of pain or proctitis) - in 8 (3.9%) and in 7 (3.4%) patients relapse of the disease was noted with the ineffectiveness of therapy. CONCLUSION: The ineffectiveness of complex conservative treatment for more than two weeks, with a history of more than 3 months, is an indication for surgical treatment. Preoperative functional and clinical and physiological examination of patients allows the formation of surgical tactics. A differentiated approach to the choice of treatment method, as well as individual determination of indications for surgery and sphincterotomy can improve long-term results. The technique of simultaneous operations with the combination of anal fissure and other proctological diseases needs to be improved.

[SURGICAL TREATMENT OF POSTOPERATIVE STRICTURE OF ANAL CHANNELL].

The results of treatment of 50 patients, suffering postoperative stricture of anal channell (SACH), who were treated in Proctology Department of Ivano-Frankivskiy Rural Clinical Hospital in 2006-2014 yrs, were analyzed. After conduction of hemorrhoidectomy in accordance to Milligan-Morgan method for chronic hemorrhoids grades III-IV a SACH have occurred in 46 (92%) patients, excision of a chronic anal fissura was performed in 3 (6%) and excision of perianal pointed condylomas--in 1 patient. In 2006-2007 yrs 11 (22%) patients were operated in accordance to approaches, which were conventional at that time (comparison group). In 2008 - 2014 yrs 39 (78%) patients were admitted to hospital (main group), in whom new approaches for diagnosis, conservative and surgical treatment were applied, 30 (76.9%) of them were operated. The proposed method on isolated roentgen contrast investigation of anal channell have permitted to determine objectively a form, diameter and grade of the anal channel stricture, and it may be applied as a screening procedure, as additional objective criterion while choosing a surgical tactic. Application of the improved operative technique for SACH have permitted to lower its occurrence rate from 45.4 to 6.7%.

Efficacy and safety of subcutaneous lateral internal sphincterotomy for chronic anal fissure.

BACKGROUND: This study was undertaken to determine the efficacy and safety of subcutaneous lateral internal sphincterotomy (SLIS) for chronic anal fissure by assessing the relief of defecatory pain, duration of wound healing and associated complications such as bleeding, infection, and anal incontinence. METHODS: This descriptive case series was carried out at the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad from September 1, 2008 to February 28, 2009. RESULTS: Out of fifty patients 31 were males and 19 were females. The mean age was 30.04 ± 8.49 years. Defecatory pain and bleeding per rectum were the commonest symptoms, found among all patients. Symptomatic relief of pain following surgery was observed among all patients at 4th week while all fissures healed at 8th week. At 4th weeks follow-up visit none of the patients had flatus incontinence while at 8th weeks all patients had good faecal continence. Majority (76%) of the patients were managed as Day case or Extended day case surgeries. There was no in-hospital mortality in this case series. CONCLUSION: SLIS is a valuable surgical procedure for patients with chronic anal fissure. It is effective and safe, offers quick relief of defecatory pain, and promotes early fissure healing without being attended by any major complications. The initial transient incontinence of flatus and faeces improves spontaneously over few weeks period. Majority of the patients are manageable on day case or extended day case surgery basis.

[Magnetledtherapy in the treatment of postoperative pain caused anal fissure--a case report]. / Magnetoledoterapia w leczeniu bólu po operacji szczeliny odbytu--opis przypadku.

Anal fissures occur most often as a result of mechanical damage or strenuous activity or cracks in structures lining the final stretch of the anal canal. They can also be the result of frequent constipation and anal intercourse. The consequence of these changes are creating cracks, sores and painful rectal spasms that cause very intense and uncomfortable pain. Initially conservative treatment is introduced. In the absence of satisfactory results, the only effective treatment is surgery. In this paper he results of treatment of a 63-year-old patient after surgery of anal fissures is introduced. The treatment included magnetledtherapy procedures. For several years, the patientfelt a persistent and very strong pain. Aftertreatment, there is significant pain relief occurring and significant improvement in quality oflife of the patient. The results of treatment show that in the complex process of treatment it is also essential to take into accountthe procedures of physical medicine.

Does Adding a Fissurectomy to Botox Sphincterotomy Increase Success Rate or Just Cost?

BACKGROUND: While Botox sphincterotomy with or without fissurectomy has been proven effective in healing anal fissures, they have not been directly compared. We evaluated cost-effectiveness and outcomes between Botox sphincterotomies with and without fissurectomy. METHODS: A 5-year retrospective review was conducted comparing all patients undergoing Botox sphincterotomy for anal fissure with or without fissurectomy. Outcomes including recurrence/persistence, additional treatments, complications, and total charges were compared between study groups. RESULTS: Patients treated without fissurectomy (n = 53) had recurrent/persistent fissure more often (56.6 vs 31.0%, P = .001), and required more Botox treatments. Those treated with fissurectomy (n = 154) had more complications (13.5 vs 0%, P = .003). Patients initially treated without fissurectomy had a median total charge of $2 973, while median total charge for those initially treated with fissurectomy was $17 925 (P < .001). CONCLUSIONS: Botox sphincterotomy in an office without fissurectomy is a viable option. It may result in longer healing times but is associated with reduced cost, lower complication rates, and no need for anesthesia or operative intervention in most cases. But the choice of treatment route must be individualized.

Surgeons' practice and preferences for the anal fissure treatment: results from an international survey.

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results.

Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey.

BACKGROUND: Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. METHODS: A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. RESULTS: 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. DISCUSSION: Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.

Treatment of anal fissures: Results from a national survey on French practice.

BACKGROUND: Treatment of an anal fissure (AF) is based on medical treatment (nonoperative therapies) and surgical procedures. However, the choice of treatment and its role in therapeutic strategy vary from one country to another, and to date, no standard French recommendation is currently available. Our aim was to assess French practices in the treatment of AFs. METHODS: A national survey of members of the French National Society of Colo-Proctology (SNFCP) was carried out using an online questionnaire (1) to evaluate French practice and (2) to compare them with guidelines of other societies. RESULTS: Two hundred responses were obtained among the 300 registered members, representing a participation rate of 67%. Members of the SNFCP agree with all scientific societies on the importance of first-line medical treatment, with surgery proposed as a second-line treatment in the case of the failure of well-conducted medical treatment. However, calcium channel blockers and topical nitrates as first-line treatment are rarely prescribed in France. Priority is therefore given to "simple" topical healing products and oral analgesics on demand. Similarly, surgical management differs since LIS is the "gold standard" in most guidelines, whereas in France, despite the data in the literature, fissurectomy is the first-line treatment. CONCLUSIONS: Our study indicated the fissure treatment discrepancies of France with other countries concerning the usage of topical treatments and the choice of first-line surgical treatments that is currently considered a "French exception".

Long-term fecal incontinence after lateral internal sphincterotomy for anal fissure.

<b>Introduction:</b> Anal fissure is a common benign anal condition. The gold standard treatment is lateral internal sphincterotomy (LIS), and this procedure carries a risk of incontinence. </br></br> <b> Aim:</b> The aim of this study is to determine the long-term risk of fecal incontinence after LIS. </br></br> <b> Method:</b> All patients who had LIS for chronic anal fissure between the years 2004-2010 were interviewed by phone and assessed for sphincter function (incontinence) using Wexner fecal incontinence score (WIS). </br></br> <b>Results:</b> Fifty-nine patients (34 females, 57.6%) with a mean follow-up duration of 10.6 years (range 8-15 years) were interviewed. Twelve patients (20.3%) had a WIS score of one or more. The majority of the patients noticed a change in sphincter function years after the operation. There was no association between vaginal delivery and the WIS score. </br></br> <b>Conclusion:</b> The long-term risk of abnormal sphincter function after LIS appears to be higher than expected, especially in the presence of multiple vaginal deliveries or systemic diseases such as diabetes mellitus. A larger prospective study is required to establish a correct risk of incontinence in the long term.